MEDICARE: JESSICA BOUTON LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	021413	NY

General Provider Information

NPI Number	:	1891290060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA BOUTON LMT

Provider Business Mailing Address
First Line	:	74 MAIN ST
Second Line	:
City	:	DELHI
State	:	NY
Zip	:	13753-1158
Country	:	US
Telephone Number	:	845-428-1735
Fax Number	:	607-746-9700

Provider Business Practice Location Address
First Line	:	74 MAIN ST
Second Line	:
City	:	DELHI
State	:	NY
Zip	:	13753-1158
Country	:	US
Telephone Number	:	845-428-1735
Fax Number	:	607-746-9700

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2018
Last Update Date	:	03/28/2018

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